Workers Compensation Verification Form - 2013

WORKERS COMPENSATION VERIFICATION

TO:

RE:

Name

Social Security Number

FROM:

Thank you for your prompt response. All information is confidential.

Please contact

.

at (

)

if you have any questions

PERMISSION FOR RELEASE OF INFORMATION

You do not have to sign this form if either the requesting organization or the organization supplying the information is left blank.

Release: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are

circumstances which would require the owner to verify information that is up to 5 years old, which would be authorized by me on a separate consent, attached to a copy of this

consent.

Signature

Date

THIS SECTION TO BE COMPLETED BY COMPENSATION PERSONNEL

Current Gross Benefit:

$______________

or

$

Week

Month

Date of Initial Award:

$

Effective Date of Current Amount:

$

Total Gross Benefit expected for the next 12 months:

$

Additional information, if any:

INSURANCE PROVIDER

Signature:

Date:

Print your name:

Title:

Tel. #:

Company Name:

Address

PENALTIES FOR MISUSING THIS CONTENT: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making

false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be

subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based

on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains, or discloses any information under

false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected

by negligent disclosure of information may bring civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD or

the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social

Security act at 208 (a) (6), (7) and (8). Violations of these provisions are cited as violations of 42 USC 408 (a), (6), (7) and (8).

Workers Compensation Verification

MN Housing 1/13